Peritonitis 4n2f38

PERITONITIS M. IQBAL RIVAI

PERITONEUM Function of peritoneum

Pain perception Visceral lubrication Fluid and particulate absorption Inflammatory and immune response Fibrinolytic activity ‘ABDOMINAL POLICEMAN’

PERITONEUM Causes of peritoneal inflammatory exudate:

Bacterial infection  appendicitis Chemical injury  bile peritonitis Ischaemic injury  strangulated bowel, vasc. Occlusion

Direct trauma  operation Allergic reaction  starch peritonitis

ACUTE PERITONITIS Bacteria in peritonitis

Gastrointestinal source  Eschericia coli  Streptococci (aerobic and anaerobic)  Bacteroides  Clostridium  Klebsiella pneumoniae  Staphylococcus

Other sources  Chlamydia  Pneumococcus

ROUTE OF INFECTION Paths to peritoneal infection

Gastrointestinal perforation  perforated ulcer Exogenous contamination  drains, open surgery

Transmural bacterial translocation (no perforation)  inflammatory bowel disease, appendicitis, ischaemic bowel

Haematogenous spread  septicemia

PERITONITIS Mortality in peritonitis reflects:

The degree and duration of peritoneal contamination

The age of the patient The general health of the patient The nature of the underlying cause

ABDOMINAL REGION

DIFFUSE PERITONITIS Factors of the development of diffuse peritonitis:

Speed of peritoneal contamination Stimulation of peristalsis by ingestion of food or even water hinders localisation

Virulence of the infecting organism Young children have a small omentum Disruption of localised collections Immune deficiency

CLINICAL FEATURES IN PERITONITIS  Abdominal pain, worse on movement  Guarding/ rigidity of abdominal wall  Pain/ tenderness on rectal/ vaginal examination (pelvic peritonitis)

 Pyrexia (may be absent)  Raised pulsed rate  Absent or reduced bowel sound  ‘Septic shock’ (SIRS) in later stages

Free air

Hippocratic facies in terminal diffuse peritonits

Acute pancreatitis on CT Scan

DIAGNOSTIC AIDS  Raised white cell count and C-reactive protein are usual  Radiographic of the abdomen  Gas-filled loop of bowels (paralytic ileus)  Free gas

 Serum amylase estimation  For acute pancreatitis (serum amylase >4x normal)

 Ultrasound and CT Scan  Used to identify the cause of peritonitis

 Peritoneal diagnostic aspiration

TREATMENT  General care of patient  Correction of fluid and electrolyte imbalance  Insertion of nasogastric tube  Broad-spectrum antibiotics  Analgesia (if diagnosis is confirmed as peritonitis)

 Operative treatment

SURGERY To eliminate the source of contamination

To reduce the bacterial contamination To prevent further complications and sepsis

SYSTEMIC COMPLICATIONS OF PERITONITIS  Bacteraemic/endotoxic shock  Bronchopneumonia/respiratory failure  Renal failure  Bone marrow suppression  Multisystem failure

ABDOMINAL COMPLICATIONS OF PERITONITIS  Adhesional small bowel obstruction  Paralytic ileus  Residual or recurrent abscess  Portal pyaemia/live abscess

PROGNOSIS Untreated peritonitis is poor, usually resulting in death.

With therapy, prognosis is variable, dependent on the underlying causes.

PREVENTIVE CARE There is “NO WAY” to prevent peritonitis, since the diseases it accompanies are usually not under the voluntary control of an individual.

However, the best way to prevent serious complications is to seek medical attention as soon as symptoms appear.

SPECIAL FORMS OF PERITONITIS  Postoperative  Leakage post anastomosis  Anastomosis dehisence  Antibiotic therapu alone is inadequate

 In patient on treatment with steroids  Pain is frequently slight or absent

 In children  Diagnosis more difficult  Gentle, patient and sympathetic approach is needed

 In patients with dementia  Unable to give reliable history  Abdominal tenderness is well localised  Guarding and rigidity are less because abdominal muscles are often thin and weak

SPECIAL FORMS OF PERITONITIS Bile peritonitis

Causes of bile peritonitis  Perforated cholecystitis

Post cholecystectomy  Cystic duct stump leakage  Leakage from an ry duct in the gallbladder bed  Bile duct injury  T-tube drain dislodgement (or tract rupture on removal)

Following other operations/procedures  Leaking duodenal stump post gastrectomy  Leaking biliary-enteric anastomosis  Leakage around percutaneous placed biliary drains

Following liver trauma

SPECIAL FORMS OF PERITONITIS Starch peritonitis

Found disfavour as a surgical glove lubricant In sensitive patients, it causes a painful ascites Laparotomy  small granulomas may be found that contain statch particles

TUBERCULOUS PERITONITIS  Acute and chronic forms  Abdominal pain, sweats, malaise and weight loss are frequent

 Caseating peritoneal nodules are common –

distinguish from metastatic carcinoma and fat necrosis of pancreatitis

 Ascites common, may be loculated  Intestinal obstruction may respond to antituberculous treatment without surgery

TUBERCULOUS PERITONITIS Origin of infection:

Tuberculous mesentric lymph nodes Tuberculosis of the ileocaecal region A tuberculous pyosalpinx Blood-borne infection from pulmonary tuberculosis

TUBERCULOUS PERITONITIS Varieties of tuberculous peritonitis

Ascitic form Encysted form Fibrous form Purulent form (rare)

PNEUMOCOCCAL PERITONITIS  Primary pneumococcal peritonitis may complicate nephrotic syndrome or cirrhosis in children

 Particularly girls between 3 and 9 years of age  route of infection: vagina and fallopian tubes

 Route of infection in males  blood-borne and secondary to respiratory tract or middle ear disease

 Onset is sudden, pain localised to the lower half of the abdomen

 Temperature raise to 39°C  Frequent vomiting  Profuse diarrhea is characteristic after 24-48 hours  Increased frequency of micturation

PNEUMOCOCCAL PERITONITIS  Treatment:  Antibiotic therapy  Correction of imbalance electrolye and dehydration  Early surgery

TERIMA KASIH